BULACAN STATE UNIVERSITY COLLEGE OF NURSING S.Y.

2013-2014

A CASE STUDY OF 47 YEARS OLD FEMALE WITH ABNORMAL UTERINE BLEEDING

SUBMITTED BY: GROUP 2B BSN 3-D LEADER: Dela Cruz, Mary Grace C. MEMBER:
Maluyo, Sarah S. Masangcay, Milcah Lornel E. Masangkay, Kriselle Karissha T. Montales, Michelle D. Pascual, Rotche M.

SUBMITTED TO: Daisy S. Reyes, RN, MAN CLINICAL INSTRUCTOR

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I.

INTRODUCTION

This is a case study of Mrs. N.Y.P., 47 years old married from Telepayong, Arayat, Pampanga. The client was admitted last May 16, 2013 (4:45pm) at Jose B. Lingad Memorial Regional Hospital, accompanied by her sister with chief complain of prolonged and heavy menses. According to our client, she experienced heavy menses for 12 days and consuming 8 baby diapers daily which prompted her for consult. D and C, also called uterine scraping, refers to dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and or contents of the uterus by scraping and scooping. It may be performed in the hospital or in a clinic while you are under general or local anesthesia. The health care provider will insert an instrument called a speculum into the vagina. This holds open the vaginal canal. Numbing medicine may be applied to the opening to the uterus (cervix).The cervical canal is widened using a metal rod, and a curette (a metal loop on the end of a long, thin handle) is passed through the opening into the uterus cavity. The doctor gently scrapes the inner layer of tissue called the endometrium; the tissue is collected for examination. This procedure may be done to diagnose conditions such as uterine cancer, remove tissue after miscarriage, treat heavy menstrual bleeding, perform an elective abortion and investigate infertility. Your doctor may also recommend D and C if you have endometrial polyps, thickening of the uterus, bleeding after menopause, and abnormal bleeding while on hormonal replacement treatment. Risk related to D and C includes puncture of the uterus, tear of the cervix and scarring of the uterine lining. Dilatation and Curettage has been associated with 4-10% rate of post complications.

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II. OBJECTIVES CLIENT CENTERED KNOWLEDGE: To provide client education appropriate to her condition. To involve the client in implementing therapeutic regimen to promote understanding compliance. To impart knowledge to patient and significant others about the procedure done and its complications. SKILLS: To help the patient in motivating her to continue the health care provided by the health care worker. To conduct physical assessment and interpret it in order to give the care the patient needed. To be able to take care of herself even outside the hospital. ATTITUDE: To be able to comply with treatments to promote recovery. To raise level of awareness on health problems that she may encounter. To encourage the client and her family to ask question so that information could be clarified. STUDENT CENTERED KNOWLEDGE: To know more about nursing responsibilities in handling patient who undergone Fractional dilatation and curettage. To be familiar with the procedure that may help us in doing health teaching with our client. To gain more knowledge about pharmacologic treatment given to a client who undergone Fractional dilatation and curettage. SKILLS: To do the necessary nursing intervention in hospital for the client. To give the known medication as prescribed by the doctor for the client. To collect and organize relevant information concerning the clients current health status. ATTITUDE: To give the proper care and build a genuine nurse-patient relationship conducive to good health. To establish appropriate behavior such as honest, reliable, courteous, and open minded. To develop our nursing responsibilities in dealing with the client. Page | 3

III.

NURSING HEALTH HISTORY A. PATIENTS PROFILE Name: Address: Birthday: Age: Sex: Civil Status: Religion: Nationality: Educational Attainment: Occupation: Source of Medical Care: Date of Admission: Initial Diagnosis: Final Diagnosis: Attending Physician: Operation Done: Admitting Institution:

Mrs. N.Y.P. Telepayong, Arayat, Pampanga May 6, 1966 47 years old Female Married Roman Catholic Filipino College Graduate Teacher (Elementary) PhilHealth May 16, 2013 (4:45pm) Abnormal Uterine Bleeding, Anemia Abnormal Uterine Bleeding, Anemia secondary controlled Dr. Ramos Fractional Dilatation and Curettage Jose B. Lingad Memorial Regional Hospital

B. REASON FOR VISIT (CHIEF COMPLAIN) The client experienced body weaknesses, easy fatigability, abnormal and heavy menses for 12 days. C. HISTORY OF PRESENT ILLNESS 12 days prior to admission, patient stated having massive bleeding consuming about 8 baby diapers a day and persistence with body weakness. Her doctor advised her to undergo blood transfusion because of her decreasing hemoglobin and must undergo fractional dilatation and curettage. Page | 4

D. HISTORY OF PAST ILLNESS Our client stated that she never got sick even her childhood days. She also had complete vaccine (as her mother told her). She had no accidents or injuries. The client has no allergies. Previous hospitalization was on 2006 in Angeles, Pampanga for the normal delivery of her 5 th child. Last 2 weeks, she experienced heavy menses with lumps noted accompanied by body weakness and easy fatigability. She consumed 8 baby diapers a day. According to our client, it was not her regular menstruation period. She usually consumed 2 to 3 napkins a day. Because of the above symptoms, she decided to consult a doctor. E. FAMILY HISTORY OF ILLNESS (GENOGRAM) According to our client, her family doesnt have any illnesses except Diabetes Mellitus of her father.

OA
LEGEND: - male Mr. A.Y. 72 y/o DM

OA

OA

OA

- female

Mrs. V.Y. 74 y/o A/W

- deceased

- deceased
Mrs. N.Y.P. 47 y/o D&C

- client

Mr. A.Y. Jr. 44 y/o A/W

Mrs. V.N. 41 y/o A/W

A/W - alive & well DM - diabetes mellitus OA - old age

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F. GORODNS FUNCTIONAL HEALTH PATTERN FUNCTIONAL HEALTH PATTERN Health Perception and Health Management PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

Our client took Vitamin C and B complex. She does not Our client is strong. According to her, she will follow doctors smoke nor drink alcoholic beverages. Mrs. N.Y.P doesnt order. have monthly check-up. When one of her siblings got sick she gave over the counter drug. Mrs. N.Y.P usually prefers to eat any kind of vegetables Our client was ordered Nothing per Orem last May 21, 2013 and fruits rather than meat. She personally cooked their in preparation of dilation and curettage. meals and dont want to buy outside. According to our client, she gained weight when she delivered her second baby. Our client does have dentures. 3 DAY DIETARY RECALL 3 DAY DIETARY RECALL Date Breakfast Lunch Dinner Date Breakfast Lunch Dinner May 13, 2013 1 cup of rice 1pc. Fried egg 250ml of coffee with creamer 1 cup of rice 1 pc. tortang talong 350ml of water 1 cup of rice Small bowl ginisang togue 300ml of water May 20, 2013 1 serving of sopas 250ml of coffee cup of rice 1 pc. tortang talong 250ml of water NPO cup of rice Small bowl of pakbet 250ml of water

Nutritional and Metabolic Pattern

May 14, 2013

3 pcs. of bread 250ml of coffee with creamer 150ml of

1 cup of rice 1 cup of rice 1 pc. Fried Small bowl fish of corned 300ml of beef with water potato 250ml of

May 21, 2013

1 pack of crackers (magic crackers) 150ml of water

NPO

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water

water May 22, 2013 1 pc of sandwich 300ml water 1/2 cup of rice Small bowl of ginisang upo 250ml of water 2 pcs of bread 250ml of water

May 15, 2013

1cup of rice 3pcs. tuyo 1pc. Egg 250ml of coffee with creamer

1 cup of rice 1 cup of rice Small bowl 2pcs. of sinigang longganisa na baboy 300ml 350ml of water water

Elimination Pattern

Our client stated that she does not have difficulties urinating and defecating. She usually urinates 3 to 4 times a day and it is slightly yellow in color. She void every morning. It is brown and formed stool.

No changes.

Activity and Exercise Pattern

Mrs. N.Y.P is an elementary teacher. Her typical day During hospitalization, she can still do everything but she include cleaning their house, cooking and then go to needs assistance when she wants to stand and walk. school for her work. She doesnt have exercise but according to her doing household chores and everyday walking going to school is an exercise. 0 feeding 0 bathing 0 toileting 0 bed mobility 0 dressing 0 grooming 0 ambulation 0 cooking 0 shopping 0 home maintenance 0 feeding 1 bathing 1 toileting 0 bed mobility 0 dressing 0 grooming 0 ambulation n/a cooking n/a shopping n/a home maintenance

Level 0 full self care Level 1 requires use of equipment

Level 0 full self care Level 1 requires use of equipment Page | 7

Level 2 requires assistance or supervision from another Level 2 requires assistance or supervision from another person person Level 3 requires assistance or supervision from another Level 3 requires assistance or supervision from another person or device person or device Level 4 dependent or does not participate Level 4 dependent or does not participate

Sleep and Rest Pattern

The client sleeps at 11pm and wakes up around 5:30am. During hospitalization, she cannot sleep well because it was She usually takes a nap during her rest day every Saturday not comfortable. She stated that it was too hot in the and Sunday. Also watching television during rest day is her hospital. Sometimes she takes a nap in the afternoon. form of relaxation. Our client is a college graduate and a board passer. She is oriented in time, place and person. The client still had a good vision and can read a nameplate 2 feet away from her. She could hear watch tick test 5 inches away. She does not have problem on her sense of taste, touch and smell. No changes

Cognitive and Perceptual Pattern

Self-Perception and Self-Concept

The patient views herself as a kind and loving person. She She accepts her condition being hospitalized. She added that also thinks positively. Her sister describes her as a caring she wants to go home as soon as possible. person and very responsible. She states that she is very happy with her life. She thinks that there is nothing wrong with her body and that her illness didnt change the way she looked at her self. The patient has a nuclear family. When problem arises, The patient has been doing well on interacting and she and the rest of her family talk about it to solve it. She communicating with different people around her. states that it usually her husband who makes the decision but she always trust her husbands decision because it works out for the best. Page | 8

Role and Relationship Pattern

Sexuality and Reproductive Pattern

Her menarche starts when she was 13 years old. Her last After dilation and curettage, the client stated that this menstrual period was May 5 up to May 16, 2013 and procedure would not affect her womanhood. She would still according to her it was not her regular menses. Her first continue her life just like before she hospitalized. sexual contact was with her husband when she was 23 years old and was only her sexual partner as well as her partner also. She claims that she did not use any kind of contraceptives. Our client is a G6 P5005. According to her, she had a monthly check-up during her past pregnancies.

Coping Stress Pattern

Watching her favorite Telenovela is her form of relieving The client doesnt feel alone because her relatives and family stress. When she feels tense, her husband comforts her. are always visiting her in the hospital.

Value-Belief Pattern

Our client is a Roman Catholic. She always keeps her According to her, when she got home, going to church is the family together. They go to church every Sunday. She first thing she would do. states that her condition (having abnormal menses) is not a punishment from God.

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IV.

GROWTH AND DEVELOPMENT PSYCHOSOCIAL (Erik Erickson) Generativity vs. Stagnation (40-50 years old) Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail attain this skills will feel unproductive in the world. PSYCHOSEXUAL (Sigmund Freud) Genital (13 years old and above) This state begins with puberty, the production of sexual hormones and maturation of the reproductive system. Genital organs become the major source of sexual pleasure and tension. The adolescent also focuses on relationship formation and prepares for more permanent relationship (e.g. marriage). A genital sexual pleasure continues throughout adulthood into advanced years. According to our patient, she engages sexual activity with her husband only. She was fully independent. She can make decision on her own. COGNITIVE (Jean Piaget) Formal Operation (11 years old and above) It marks a movement from an ability to think and reason from concrete visible events to an ability to think hypothetically; to entertain what-if possibilities about the world MORAL (Kohlberg) Post Conventional or Principled (Stage 5) Individuals make their own choices, understanding the views of other people but make their own decisions. Stage 5: Humans Rights and Social Welfare Morality Promote fundamental human rights and values Freely entered social contract to protect members rights and ensure the welfare of all Agreements determine the obligations of relationships of the individual. The patient understand the different roles of the society and can distinguish what is right or wrong based on internalized rules of conscience rather than the social law. According to her, she will follow all the orders of the doctor. Page | 10

STAGE

DEFINITION

ANALYSIS

Our patient takes the responsibility in comes of taking care her children. She tends to be more confident and feel good about herself. She was also active in their community.

The client thinks rationally and logically. She is able to solve problem with her family by communicating to them and vice versa

V.

ANATOMY AND PHYSIOLOGY EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external genital area or vulva which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy tissue surround the entrance to the vagina and the urinary opening: the labia majora, or outer folds, and the labia minora, or inner folds, located under the labia majora. The clitoris, is a relatively short organ (less than one inch long), shielded by a hood of flesh. When stimulated sexually, the clitoris can become erect like a man's penis. The hymen, a thin membrane protecting the entrance of the vagina, stretches when you insert a tampon or have intercourse.

INTERNAL REPRODUCTIVE STRUCTURE The Vagina The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where the embryo grows into a fetus during pregnancy. In the reproductive process, the vagina functions as a twoway street, accepting the penis and sperm during intercourse and roughly nine months later, serving as the avenue of birth through which the new baby enters the world. The Cervix The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix, and then proceed through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg), conception occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly Page | 11

fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery, offering a much more friendly environment to sperm as they struggle towards their goal. (This phenomenon is employed by birth control pills, shots and implants. One of the ways they prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.) Uterus The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. Oviducts The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy. Ovaries The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilised on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel

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VI.

PHYSICAL ASSESSMENT VITAL SIGNS (May 21, 2013) BP: TEMP: R.R: P.R: 120/80 mmHG 37.0 C 98bpm 20cpm TECHNIQUE NORMAL FINDINGS General appearance ACTUAL FINDINGS REMARKS

PARTS TO BE ASSESSED

1. Body built in relation to clients age, lifestyle & health

Inspection

Proportionate and varies with lifestyle Relax, erect posture, coordinated body movements Neat No body odor or minor body odor relative No distress noted

She has a proportionate body built which is appropriate with her lifestyle Cannot stand perfectly

Normal

2. Clients posture & gait, standing, sitting & walking 3. Clients overall hygiene & grooming 4. Body & breath odor 5. Signs of distress in posture or facial expression

Inspection

Deviation from normal due to dilatation and curettage Normal Normal Normal

Inspection Inspection Inspection

She is neat and clean. no body odor No distress noted

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PARTS TO BE ASSESSED 6. Obvious signs of health or illness 7. Clients attitude 8. Clients affect/mood; appropriateness of the clients response 9. Quantity of speech, quality & organization 10. Relevance & organization of thoughts

TECHNIQUE Inspection Inspection Inspection

NORMAL FINDINGS Healthy appearance Cooperative Appropriate to the situation Understandable, moderate pace; exhibits thought association Logical sequence; makes sense; has sense of reality. SKIN

ACTUAL FINDINGS Looks weak Cooperative Appropriate to the situation

REMARKS Deviation from Normal due to lack of sleep Normal Normal

Inspection

Understandable

Normal

Inspection

has sense of reality

Normal

1. Skin moisture

Inspection

moisture in skin fold and axillae Smooth, light or dark skin tone Springs back

moisture in skin fold

Normal Deviation from normal due to decrease hemoglobin level as stated in her laboratory result. Normal

2. Skin color and texture

Inspection

Smooth but skin is pallor

3. Skin turgor

Inspection and palpation

Springs back

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Nails

ACTUAL FINDINGS

REMARKS

1. Fingernails plate shape to determine its curvature & angle

Inspection

Convex curvature, angle of nail plate about 160 degrees. Highly vascular and pink in light skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks. Intact epidermis. Smooth texture. Prompt return of pink or usual color (generally less than 4 seconds.) Hair

Angle of nail plate about 160 degrees.

Normal

2. Fingernail & toenail bed color

Inspection

Fingernail bed is pale in color

Deviation from Normal due to decrease hemoglobin level as stated in her laboratory result. Normal Normal

3. Tissues surroundings nails 4. Fingernail texture & toenail

Inspection Palpation

She has an intact epidermis with no hangnails Smooth nail texture The color return to the original color in 2 seconds

5. Blanch test of capillary refill

Palpation

Normal

1. Evenness of growth over the scalp 2. Hair thickness & thinness

Inspection Palpation

Evenly distributed hair. Thick/thin hair.

Her hair is well distributed has a thick hair

Normal Normal Page | 15

PARTS TO BE ASSESSED 3. Presence of infections or infestations 4. Texture & oiliness over the scalp

TECHNIQUE Inspection Palpation

NORMAL FINDINGS Not present. Silky, resilient hair. SKULL Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses. FACE Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Symmetrical facial movements.

ACTUAL FINDINGS Not present. Silky, resilient hair.

REMARKS Normal Normal

1. Size, shape, symmetry

Palpation

Head is symmetrically rounded

Normal

2. Nodules or masses and depressions

Palpation

No mass or nodules

Normal

1. Facial features

Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Facial movements are symmetrical

Normal

2. Symmetry of the facial movements

Inspection

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Eyebrows and Eyelashes Hair evenly distributed; skin intact. Eyebrows asymmetrically aligned equal movement. Eyelashes curl slightly outward. Eyelids Skin intact, no discharge, no discoloration. Lids close symmetrically approximately 15-20 involuntary blinks per minute; bilateral blinking. When lids open, no open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. CONJUNCTIVA

ACTUAL FINDINGS

REMARKS

1. Evenness of distribution & direction of curl

Inspection

Eyebrows and eyelashes are both evenly distributed, symmetrical aligned. Eyelashes curl slightly outward.

Normal

1. Surface characteristics & ability to blink

Inspection and Palpation

Eyelids skin are intact, no noted discharge, and no noted discoloration. Lids close symmetrically. Client exhibited 18 involuntary blinks per minute.

Normal

1. Bulbar conjunctivas color, texture and presence of lesions 2. Palpebral conjunctivas color, texture & presence of

Inspection

Transparent; capillaries sometimes evident.

Transparent, capillaries evident, no discharge was noted. Shiny, smooth but pale in

Normal

Inspection

Shiny, smooth, pink or red in

Deviation from Normal due to decrease hemoglobin level as Page | 17

PARTS TO BE ASSESSED lesions

TECHNIQUE

NORMAL FINDINGS color. Sclera

ACTUAL FINDINGS color.

REMARKS stated on her laboratory result.

1. Color & clarity

Inspection

Sclera appears white (yellowish in dark- skinned clients). Cornea Transparent, shiny and smooth; details of the iris are visible. In older people, a thin grayish white ring around the margin, called arcussenilis, may be evident. Iris

Sclera appears white

Normal

1.Clarity & color

Inspection

Details of iris are visible. Transparent, shiny and smooth.

Normal

1. Shape & color

Inspection

Flat and round Pupils

Flat and round and uniform in color.

Normal

1. Color, shape & symmetry of size

Inspection

Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border.

Firm and equal pupils

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS EARS AURICLE Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10cm from vertical. Mobile, firm and not tender, pinna recoils after it is folded. Nose

ACTUAL FINDINGS

REMARKS

1. Color & symmetry of size & position

Inspection

Color is same with facial skin, symmetrical with each other, auricle aligned with outer canthus of eye, about 10 cm vertical Both pinna recoils after being folded. Mobile, firm and not tender.

Normal

2. Texture & elasticity & areas of tenderness

Palpation

Normal

1. Shape, size or color & flaring or discharge from the nares 2. Presence of redness, swelling, growths & discharge or nares using the flashlight 3. Position of nasal septum

Symmetric and straight Inspection No discharge or flaring Uniform color Mucosa pink Inspection Clear, watery discharge No lesions. Inspection Nasal septum intact and in midline, intact

No discharge or flaring of the nose. Symmetrical on both sides. Also uniform in color. Mucosa is intact and pinkish; minimal moist noted inside; no swelling or nodules found. Nasal septum is intact and in midline

Normal

Normal

Normal

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PARTS TO BE ASSESSED 4. Test patency of both nasal septum 5. Tenderness, masses & displacement of bone & cartilage

TECHNIQUE

NORMAL FINDINGS Air moves freely as the client breathes through the nares Not tender; no lesions Lips Uniform pink color

ACTUAL FINDINGS Air moves freely as the client breathes through each nares No tenderness, no lesions noted. No displacement of bone & cartilage.

REMARKS

Inspection

Normal

Palpation

Normal

Uniform but pale in color Soft, moist, smooth texture Symmetry of contour Has the ability to purse lips Deviation from Normal due to decrease hemoglobin level as stated in her laboratory result.

1. Symmetry of contour color & texture

Inspection and Palpation

Soft, moist, smooth texture Symmetry of contour Ability to purse lips Teeth

1. Inspect for color, number & condition & presence of dentures

32 adult teeth Inspection Smooth, white, shiny tooth enamel Gums She has smooth shiny 32 teeth Normal

1. Color & condition

Inspection

Pink gums (bluish or dark patches in dark-skinned clients)

Pink gums (bluish or dark patches in dark-skinned clients)

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Moist, firm texture to gums

ACTUAL FINDINGS Moist, firm texture to gums

REMARKS

TONGUE/FLOOR OF THE MOUTH 1. Color & texture of the mouth floor & frenulum Inspection and Palpation Smooth tongue base with prominent veins Central in position Pink in color (some brown pigmentation on tongue borders in darj-skinned clients); moist; slightly rough; thin white coating Smooth, lateral margins, no lesions Raised papillae (taste buds) Moves freely, no tenderness Abdomen Unblemished skin, uniform in color, silver white striae (stretch marks) or surgical scars. Smooth tongue base with prominent veins Central in position Pink in color (some brown pigmentation on tongue borders in dark-skinned clients); moist; slightly rough; thin white coating Smooth, lateral margins, no lesions Raised papillae (taste buds) Moves freely, no tenderness Normal

2. Position, color & texture, movement & base of the tongue

Inspection and Palpation

Normal

1. Skin integrity

Inspection

She has stretch marks

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Flat, rounded (convex) or scaphoid(concave)

ACTUAL FINDINGS

REMARKS Normal

2. Abdominal contour

Inspection

Convex in shape.

3. Bowel Sounds

Auscultation

Audible bowel sounds

Audible bowel sounds

Normal

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VII.

LABORATORY / DIAGNOSTIC TEST DATE ORDERED INDICATION / PURPOSE NORMAL VALUES ACTUAL VALUES ANALYSIS AND INTERPRETATION OF RESULTS NURSING RESPONSIBILITIES

DIAGNOSTIC/ LABORATORY PRODCEDURE Urinalysis

May 16, 2013

Urinalysis are usually used to as a general health screening test to detect renal and metabolic diseases diagnosis of diseases or disorders of the kidneys or urinary tract monitoring of patients with diabetes In addition, quantitative urinalysis tests may be performed to help diagnose many specific disorders, such as endocrine diseases, bladder cancer, osteoporosis, and porphyrias (a group of disorders caused by chemical imbalance).

Color: Dark Yellow to amber Appearance: Clear Odor: Aromatic pH: 4.6 8 Specific Gravity: 1.005-1.030

Color: Yellow Appearance: Clear Odor: Aromatic pH: 3 Specific Gravity: 1.030

Within normal Prior: Check the doctors order. range except for Teach the client on how to the pH which collect a specimen. indicates acidity of Prepare a clean dry bottle her urine.
with label. During: Instruct the client to collect midstream urine only. After: Wipe excess urine in the bottle and cover it. Send urine to the laboratory immediately.

Hematology: Hemoglobin May 19, 2013 Hemoglobin is an important component of 115-155 g/L 105 g/L Below normal Page | 23

red blood cells that carries oxygen and carbon dioxide to and from tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. The oxygen carrying capacity of the blood is also determined by the hemoglobin concentration.

range. It means that the client has Prior: Check the doctors order. an anemia. Explain the procedure to the Common causes client. include excessive bleeding, a During: deficiency Use standard precaution and of iron,vitamin B12, sterile technique when or folic acid, getting specimen. destruction of red Apply pressure on the cells by antibodies venipuncture site after or mechanical withdrawing specimen. trauma, and structurally After: abnormal Label the specimen container with name, age, hemoglobin.
date and time, the specimen you obtained, room number, and the doctor who ordered the specimen.

Hematocrit

May 19, 2013

It measures the percentage of RBC in a blood volume. The test is perform to help diagnose blood disorders, such as polycythemia, anemia or abnormal dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those transfusions.

0.38 0.48

0.31

Below normal range. It is maybe due to chronic and recent acute blood loss, some cancers, kidney and liver disease, malnutrition, Vit. B12 and folic acid deficiencies, iron deficiency, pregnancy, and peptic ulcer.

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VIII. PATIENT AND HIS CARE A. MEDICAL MANAGEMENT Medical Management Treatment Date ordered/ date performed/ date discontinue Date ordered/performed: May 16, 2013 General Description Indication/ Purpose Clients Response to the treatment Nursing Responsibilities

IVF D5LR 1cc

Dextrose Lactated Ringers solution D5LR 1cc to run at 3031gtts/min

It is used to supply water and electrolytes loss (Calcium, Potassium, Sodium and Chloride).

Date Discontinue: May 22, 2013

Signs and symptoms Prior: of dehydration were Check the doctors not noted such as order for IVF insertion, dry skin. its drop factor and ordered amount. During: Secure the tube; make sure that the tube is not dislodging when the patient moves. Check for possible complication such as infection. Observed for the IV site for its appearance. Check for the patency. After: Evaluate the patients response to the treatment.

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Medical Management Treatment

Date ordered/ date performed/ date discontinue Date ordered/performed: May 17, 2013 (5:00am 11:15am) May 18, 2013 (8:20pm 2:30am) May 19, 2013 (6:00am 11pm) Date Discontinue: May 19, 2013

General Description

Indication/ Purpose

Clients Response to the treatment

Nursing Responsibilities

Blood Transfusion (Pack RBC) Blood Type: B

Blood transfusion involves transfusing whole blood or blood components.

Pack RBCs indicated to increase the oxygencarrying capacity of blood with minimal expansion of blood. It is also to maintain hemoglobin level in clients with severe anemia.

Signs and symptoms allergic reactions to blood were not noted.

Prior: Check the doctors order. Inform the client and explain the purpose of the procedure. Check for cross matching and typing. During: Obtain and record baseline data. Practice strict aseptic technique. Atleast 2 licensed nurse are with you and check the label of the blood transfusion before, during and after giving it to the patient. After: Administer BT for 4 hours only. Observe for possible complication. Evaluate the patients response to the treatment.

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B. DRUGS Generic Name / Brand Name / Classification Date Route of (Ordered, given, Administration, changed, discontinue) dosage, frequency Date ordered / given: May 16, 2013 Date Discontinue: May 22, 2013 Per Orem, 5mg/tab, once a day Mechanism of Action Clients Response Nursing Responsibilities

Generic Name: Amlodipine Brand Name: Norvasc Classification: Calcium Channel Blockers

Inhibits transport of calcium into the myocardial and vascular smooth muscle cells, result in inhibition of excitation-contracting coupling and subsequent contraction. Systematic vasodilation resulting in decreased blood pressure.

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PRIOR: Monitor vital signs. Advise the client to change position slowly to minimize orthostatic hypotension. DURING: Amlodipine may take with or without meal. Tell the patient that she/he may experience light headedness or dizziness. AFTER: Monitor vital signs. Advise the client to report signs and symptoms of chest pain, shortness of breathing, dizziness and altered of vision immediately.

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Generic Name / Brand Name / Classification

Date Route of (Ordered, given, Administration, changed, discontinue) dosage, frequency Date ordered / given: May 16, 2013 Date Discontinue: May 22, 2013 Per Orem, 200mg, thrice a day

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Ferrous Sulfate Brand Name: Feosol Classification: Antianemic, iron

Iron is absorbed from the duodenum and upper jejunum by an active mechanism through the mucosal cells where it combines with the protein transferrin. It is stored in the body as hemosiderin or aggregated ferritin which is found in reticuloendothelial cells of the liver, spleen, and bone marrow.

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PRIOR: Take a drug history including antacid use, OTC drugs, recent abdominal surgery, and allergies to sulfites. Assess nutritional status and diet history. DURING: Take with meals. Do not crush the tablet. Encourage to take ferrous sulfate with citrus juice. AFTER: Monitor vital signs Note any signs of GI bleeding. Note any complains of fatigue, pallor, and poor skin turgor.

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Generic Name / Brand Name / Classification

Date (Ordered, given, changed, discontinue) Date ordered / given: May 16, 2013 Date Discontinue: May 18, 2013

Route of Administration, dosage, frequency IV 1gm every 8 hours

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Traxenamic Acid

Classification: Hemostatic Agent, antifibrinolytic agent

Inhibits activation of plasminogen, thereby preventing the conversion of plasminogen to plasmin

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PRIOR: Check the doctors order. DURING: Check signs for thromboembolism such as tenderness, reddish and warm spots. AFTER: Check V/S regularly to monitor any unusualities. Instruct patient to complete drug therapy as indicated.

Generic Name / Brand Name / Classification

Date (Ordered, given, changed, discontinue) Date ordered / given: May 16, 2013 Date Discontinue: May 18, 2013

Route of Administration, dosage, frequency Per Orem, 500mg 1cap, thrice a day

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Cephalexin Brand Name: Keflex Classification: Cephalosporin

Cephalosporin stop or slow the growth of bacterial cells by preventing bacteria from forming the cell wall that surrounds each cell.

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PRIOR: Check the medications chart to reduce error in medication administration. Ask the patient if she/he has an allergy to penicillin or cephalosporin. DURING: Monitor vital signs. The drug may be taken with or without food. AFTER: Evaluate patients appearance.

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Generic Name / Brand Name / Classification

Date Route of (Ordered, given, Administration, changed, discontinue) dosage, frequency Date ordered / given: May 22, 2013 Date Discontinue: May 23, 2013 Per Orem, 500mg 1cap, thrice a day

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Mefenamic Acid Brand Name: Ponstan Classification: Analgesic, NSAID, Antipyretic

Anthranilic acid derivatives. Like ibuprofen inhibits prostaglandin synthesis and affects platelet function. No evidence that it is superior to aspirin.

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PRIOR: Check the medications chart to reduce error in medication administration. Assess patients who develop severe diarrhea and vomiting for dehydration and electrolyte imbalance. DURING: Monitor blood glucose for loss of glycemic control if diabetic. AFTER: Evaluate patients appearance.

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C. DIET Type of Diet

Date (started, discontinue) May 16, 2013 up to May 20, 2013

General Description

Indication/Purpose

Specific foods/ fluids taken

Client Response

Nursing Responsibilities

DAT (Diet As Tolerated)

It is a diet that allows the patient to eat types/kinds of foods as long as the client can tolerate it.

It is instructed following a general liquid diet for better source of good nutrition.

- Lugaw - egg and rice - pinakbet and rice - monggo and rice - sinigang na bangus and rice

Relived hunger Prior: Assess the level of understanding of the patient. Explain that immediate shifting of foods from NPO to General Fluids to DAT without undergoing soft diet can result to constipation, thats why we need to emphasize eating first soft foods before eating any solid foods. During: Strictly monitor clients behavior in following DAT diet. After: Advise the client to take soft foods and avoid food rich in fats. Prior: Assess the understanding patient.

NPO (Nothing Per Orem)

May 21,2013

Withhold oral foods and fluids from the patient

NPO is instructed to prevent aspiration usually for those

none

The client feels hungry and request food

level of

of the

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patients who would undergo surgery.

to the nurse, but the nurse refused it to do.

Explain the importance of following strictly NPO in terms that the client can understand and then evaluate.

During: Strictly monitor clients behavior in following NPO. Post: Instruct the client to continue NPO as prescribed by the Physician.

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IX.

NURSING CARE PLAN ASSESSMENT DIAGNOSIS

Ineffective Tissue Perfusion related to decrease hemoglobin concentration of the blood

PLANNING
After 1 to 2 days of Nursing Intervention, the client will be able to: Verbalize understanding of her condition, therapy regimen, and when to contact healthcare provider. Demonstrate behaviors/ lifestyle changes to improve circulation. Demonstrate increased perfusion as individually appropriate.

IMPLEMENTATION
Review results of diagnostic studies.

RATIONALE
To determine location / severity of condition. To facilitates management of the condition.

EVALUATION
After 1 to 2 days of Nursing Intervention, the client was been able to: Verbalized understanding of her condition, therapy regimen, and when to contact healthcare provider. Demonstrated behaviors/ lifestyle changes which improve circulation. Demonstrated increased perfusion.

S:

O: Decrease hemoglobin level Heavy vaginal bleeding Skin color is pale

Monitor pressure.

blood

Monitor for signs of shock.

Decreasing hemoglobin causes hypovolemic shock

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ASSESSMENT
S: Inaantok pa ako, as verbalized by the client

DIAGNOSIS
Sleep Deprivation related to discomfort and unfamiliar environment.

PLANNING
After 1 hour of Nursing Intervention, the client will be able to: Verbalize understanding of sleep disorder. Identify individually appropriate interventions to promote sleep. Adjust lifestyle to determine usual sleep habits and changes that are occurring.

IMPLEMENTATION
Ask the client to verbalize needs before going to bed.

RATIONALE

EVALUATION

O: Daytime drowsiness Lack of energy Looks weak

Encourage the client to a comfortable position and assisting in turning. Suggest abstaining from daytime naps.

Promotes bedtime After 1 hour of Nursing routine and Intervention, the client was attends client been able to: needs. Verbalized understanding of sleep disorder. Repositioning Identified individually alters areas of appropriate interventions pressure and which promote sleep. promotes rest. Adjusted her lifestyle to determine usual sleep Because they habits and changes that impair ability to are occurring. sleep at night.

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X.

DISCHARGE PLANNING MEDICINES Teach the following to the client with regards to proper administration of the prescribed medication Ferrous Sulfate tablet, 3x a day Mefenamic Acid 500mg 1cap 3x a day Cefalexin 500mg 1cap 3x a day ENVIRONMENT AND EXERCISE Encourage to establish clean and well ventilated environment Avoid exercise and heavy lifting due to the risk of infection and bleeding Instruct the client to gradually increase her activity as tolerated TREATMENT Inform clients caregiver to fully participate in continuous treatment Compliance to the medication Increase fluid intake of 2-3 Liters HEALTH TEACHING Do not have sexual intercourse for atleast two weeks to prevent infection Inform client to have a follow up checkup No strenuous activity or heavy lifting instructed to take the medications at the right route, route dose and right time encouraged eating the proper diet as advised by the doctor

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OUT-PATIENT Advise the clients caregiver to report any unusual effect of medication to the client. Follow scheduled check-up by the Doctor DIET encouraged oral fluids advised to follow the proper diet recommended instructed to avoid eating foods high in fats and cholesterol SPIRITUAL encouraged praying every day encouraged hearing mass every Sunday

XI.

CONCLUSION

This case study gave the group more knowledge in making actual management for this kind of condition. Thus, the member of the group have realized the need of promoting and maintaining optimal health to both the patient and her significant others. With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will, one can surely direct herself away from the complications.

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XII.

BIBLIOGRAPHY BOOKS: Kozier and Erbs, Fundamentals of Nursing 8th Edition, Volume 2 Elaine N. Marieb, Essentials of Human Anatomy and Physiology 8th Edition George R. Spratto and Adrienne L. Woods, Nurses Drug Handbook 2008 Edition Marilynn E. Doenges, Nurses Pocket Guide 11th Edition Karen Kowalski and Patricia S. Yoder-Wise, Rapid Reference for Nurses Elsevier Mosby, PDQ for RN

WEBSITES: www.scrbd.com http://www.surgeryencyclopedia.com www.nursingcrib.com

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